Provider Demographics
NPI:1639676547
Name:BLAKESLEE, MICHAEL SCOTT (PA-C)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SCOTT
Last Name:BLAKESLEE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 VALLEY STREET CLINICA ESPERANZA/HOPE CLINIC
Mailing Address - Street 2:SUITE 104
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02609
Mailing Address - Country:US
Mailing Address - Phone:401-347-9093
Mailing Address - Fax:401-633-6949
Practice Address - Street 1:60 VALLEY STREET CLINICA ESPERANZA/HOPE CLINIC
Practice Address - Street 2:SUITE 104
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02609
Practice Address - Country:US
Practice Address - Phone:401-347-9093
Practice Address - Fax:401-633-6949
Is Sole Proprietor?:No
Enumeration Date:2018-04-07
Last Update Date:2024-05-09
Deactivation Date:2024-04-09
Deactivation Code:
Reactivation Date:2024-05-08
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant